>The Scientist,    Volume 11 1997
>
>Homelessness Should Be Treated As A Major Health Issue
>
>by William R. Breakey                   November 10, 1997
>
>It is incongruous that in an era of great economic strength, with
>low unemployment, low inflation, a booming stock market, and high
>consumer optimism, a walk down the streets of any of our
>metropolises will reveal homeless people who are bedraggled, poor,
>and in many cases disabled by illness. It is all the more perturbing
>when one considers that these visibly destitute individuals, the
>sight of whom often offends the sensibilities of passersby, represent
>the mere tip of an iceberg of poverty and dislocation, most of which
>is invisible to the casual observer: Many homeless people are able to
>maintain a relatively normal appearance while living on the streets
>and are not particularly noticeable. In addition to street people,
>many other homeless people live in temporary or emergency shelters or
>seedy motels, and large numbers live in substandard housing or
>shanties. Yet others move in with relatives or friends because they
>cannot find, or afford, a place of their own.
>
>Estimating the numbers of homeless people is notoriously difficult,
>but clearly the scale of the problem is much greater in America than
>many people realize. A recent estimate by Bruce Link and colleagues
>at Columbia University, using a sophisticated sampling procedure,
>suggests that as many as 7 percent of Americans (13.5 million people)
>may have experienced homelessness at some time in their lives.
>
>As fall progresses toward winter, there inevitably will be a
>resurgence of public sympathy for homeless people. However,
>temperature extremes are by no means the worst aspect of being
>homeless. It is the lack of shelter, the loss of privacy, the
>exposure to infectious disease, the risk of intimidation and
>physical attack, the impermanence, and the social isolation that are
>its most injurious aspects. Journalists, activists, and advocates
>have vividly portrayed the plight of homeless people and the
>miserable conditions in which they live in America, but still not
>much happens, in terms of major public policy initiatives, to
>rectify the situation. That hundreds of thousands of people are
>homeless is a major indictment of our current political economy. It
>is also a major health issue.
>
>The relationship between homelessness and disease has been clearly
>demonstrated. Exposure to inclement weather, limited opportunity for
>maintaining personal hygiene, poor nutrition, exposure to street
>violence, sleep deprivation, heavy tobacco use, and exposure to
>alcohol and other drugs all pose health hazards, as do the
>overcrowded conditions of many shelters, with increased risk of
>exposure to parasitic or infectious diseases. Limited access to
>medical, psychiatric, dental, and podiatric care means that
>conditions that would in normal circumstances be easily resolved may
>persist, worsen, or become chronic. Homeless people have been shown
>to be at increased risk for tuberculosis and other respiratory
>diseases, trauma, schizophrenia, depression, alcoholism and its
>sequelae, drug abuse and dependence, HIV infection, and sexually
>transmitted diseases. In addition, those who are already sick and
>disabled are often at greatest risk of homelessness because of loss
>of income, because of their greater needs, because they have greater
>difficulty managing their resources, and because support provided by
>Social Security is often inadequate.
>
>Homeless families, most often consisting of mothers and children,
>have been of particular concern and are believed to be the fastest
>growing segment of the homeless population. The consequences of
>homelessness for children are grave. Residential instability in
>childhood has been associated with delays in cognitive development,
>interruption of education, frequent infections, anxiety and
>depression, and failure to obtain necessary immunizations. Homeless
>adolescents are in great danger of becoming involved in high-risk
>behaviors, including substance abuse and prostitution.
>
>Redefine Public Health Concerns
>
>The view from my office window includes rows of boarded-up city
>houses, condemned but not repaired to make them habitable, while
>hundreds, perhaps thousands, of people in the city are homeless
>today. But this is not generally thought of as a health concern:
>Policies governing housing and homelessness are considered to be
>economic or social policies, in spite of the fact that a home is as
>essential for health as are clean water, pure air, and uncontaminated
>food and that lack of a home endangers the health of individuals and
>families and that, on occasion, it endangers life itself.
>
>When a cluster of cases of coliform enteritis occurs owing to
>contaminated hamburgers, it becomes a public health emergency, and
>health agencies mobilize. Public agencies, in order to protect the
>public health, also are authorized to control the lead content of
>paints and gasoline, to control cigarette advertising, and to close
>beaches if the water is contaminated. In contrast, when a homeless
>man dies in a fire in an abandoned building where he has sought
>shelter from the cold, it is seen as a law-enforcement matter-he has
>committed crimes of breaking and entering and arson. When an epidemic
>of HIV infection or tuberculosis occurs among homeless people, health
>authorities question whether the shelters should be closed rather
>than insist that decent housing be provided as a public health
>measure.
>
>It would be unfair and inaccurate to imply that there has been no
>governmental response to homelessness. A decade ago, Congress enacted
>the Stewart B. McKinney Homeless Assistance Act (PL 100-77). Under
>the provisions of the McKinney Act, federal agencies have funded
>services for homeless people, including health care, mental health
>care, food assistance, emergency shelter, transitional housing, and
>facility construction. The act also established the Interagency
>Council on the Homeless to coordinate the activities of federal
>agencies and, in subsequent reauthorizations, additional programs
>were designed to help persons with AIDS, women in domestic violence
>shelters, and children in homeless families. A series of research
>demonstration projects has been funded to develop better models of
>serving the needs of homeless people.
>
>However, the McKinney Act was intended only as a first step. More
>far-reaching responses were to follow but have yet to be developed.
>Although immense and praiseworthy public and private effort has gone
>into providing services for homeless people in almost every state,
>there is no evidence that the extent of homelessness in America is
>less than it was a decade ago, and strong suggestions that it may be
>greater. More and more people end up in shelters or on the streets:
>There has been little or no progress toward preventing homelessness,
>in spite of the fact that preventing homelessness will promote
>health.
>
>Preventive Strategies Required
>
>Prevention is central to public health practice. Preventive public
>health strategies include immunization, smoking cessation and
>anti-drug campaigns, violence prevention, occupational safety
>measures, food inspection, control of lead in the environment,
>programs to promote balanced nutrition and dental hygiene, and water
>purification. We should now accept that the availability of adequate
>housing is an important preventive public health measure to be
>mandated by government and implemented by public agencies. This will
>require a concerted effort, supported by a national consensus that
>homelessness is as unacceptable in our society as dirty drinking
>water, dangerous workplaces, or unsafe highway bridges. It will
>require federal-state-city partnerships and the involvement of the
>private sector. Existing programs, such as Section 8 and other
>Housing and Urban Development initiatives, will need to be expanded
>and creativity applied to develop new solutions.
>
>First, housing must be available for all Americans: Currently there
>simply are not enough housing units for all of us, and there needs to
>be a massive program of housing construction. Different mechanisms
>will need to be developed to support this effort. Along with other
>initiatives, nonprofit housing construction and rehabilitation
>groups, such as Habitat for Humanity, should be encouraged and
>supported with public funds.
>
>Second, housing must be also be accessible-affordable and located in
>places where there is employment and freedom from cultural barriers,
>and with access to the other necessities for community living.
>
>Even then, many homeless people will have great difficulty in
>settling into mainstream living, either because of mental illness or
>developmental disability or because they have become acculturated to
>a different way of life. Thus the third requirement is that social
>services, health care, and other support systems be available to
>enable such people to acquire and maintain a permanent home.
>
>Science's Role In Advocacy
>
>Scientists have been effective in advocating for sane public
>policies in relation to other issues, such as nuclear disarmament and
>control of tobacco sales. Scientists, particularly those in the
>public health arena, should be equally vociferous in advocating for a
>national endeavor to ensure that every American has access to an
>adequate home as a prerequisite for healthy living.
>
>Such advocacy will bring us into the political arena in a way that
>may make us uncomfortable. In 1988 the Institute of Medicine
>published a report, Homelessness, Health and Human Needs, which
>described the very considerable body of scientific knowledge then
>available about the impact of homelessness on health. The
>report-methodical, objective, and comprehensive as it was-did not
>generate a great deal of interest outside the relatively small circle
>of health professionals, scientists, and policymakers who were
>involved with homelessness. However, a great deal of media attention
>was given to an unofficial statement signed by almost all of the
>members of the committee who authored the report, expressing outrage
>at what they had discovered as they conducted their research for the
>report about the conditions under which homeless American citizens
>were forced to live, and the impact on their health. The academy held
>that the expression of outrage had no place in a scientific document;
>the committee members felt that they could not keep silent.
>
>Scientists should not keep silent today. They should join their
>voices with public health advocates and others to impress upon
>policymakers and those who elect them that homelessness is not only
>an affront to our ideas of America as a just and prosperous society,
>but also a health hazard that can and should be recognized as such
>and eliminated, like water pollution or malnutrition. We in the
>United States have a good record in confronting awesome technical
>challenges and achieving important objectives against enormous odds
>when we establish a national consensus. Cleaning up the rivers,
>immunizing children, fighting AIDS, and exploring the solar system
>all come to mind. If we decide to do so, we can eliminate
>homelessness.
>
>------------------------
>
>William R. Breakey is a professor in the department of psychiatry
>and behavioral sciences at Johns Hopkins University School of
>Medicine.
>
>------------------------
>
>(The Scientist, Vol:11, #22, p. 8, November 10, 1997) (Copyright c
>The Scientist, Inc.)
>
>-----------------------
>
>
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